Postpartum Care andParenting

Uterus

• Involution: uterine reduction; 1 cm/day (from 1above umbilicus at 12 h)• Contractions: oxytocin; decrease bleeding• After pains: associated with multiparas,

distendeduterus, breastfeeding and uterotonic medications• Placental site: regenerates by 6 wks• Lochia: uterine discharge lasting 3-6 wks– Rubra: reddish brown; 3-4 days– Serosa: pinkish brown; 4-10 days– Alba: yellow-white, up to 6 wks)• Cervix: bruising & small lacerations common

Vagina/Perineum/Pelvic Floor Muscles

Vagina Thin, smooth walls; rugae reappear by wk 4 Dryness associated with low estrogen levels

anddyspareunia (pain with sexual intercourse)Perineum Edema, erythema and pain common Episiotomy/laceration should heal by 2 wksPelvic floor muscles May be stretched or torn; Kegal exercises

help to regain tone

Endocrine

Estrogen/progesterone levels drop, associated with breast engorgement & diuresis

Nonlactating: estrogen level rise in 2 wks;with menstruation & ovulation 4-12 weeks Lactating: estrogen rise & menses delayed(2-18 months; affected by supplementation &

breastfeeding duration) Prolactin: infant sucking stimulates productionremains elevated in lactating women; drops in

nonlactating women; suppresses ovulation

Abdomen & Urinary System

Abdomen: decreased muscle tone for 6 wksBladder: Increased capacity & decreased tone

increases risk of retention & infection If full, will displace uterus, causing uterine

atonyPostpartal diuresis 2000 to 3000 ml in first 12-24 hours Profuse diaphoresis occurs commonly at

night

Gastrointestinal

Hunger & thirst common following birth Increased risk of hemorrhoids from pushing Increased risk for constipation associated

withdecreased peristalsis, narcotic analgesics,dehydration, decreased mobility & fear of painwith bowel movement Injury to anal sphincter associated with

forceps orepisiotomy can cause bowel incontinence

Breasts

Colostrum: first milk secreted, rich in protein & immunoglobulins

Milk production begins day 3 or 4 Engorgement may occur when milk comes

in; breasts swollen, firm, warm & tender– Lactating: breastfeed/pump breasts, ice

packs to axillary area and well-fitted bra– Nonlactating: ice packs, breast binder; do

not express milk Nipples: erythema, blisters & fissures can

result from poor positioning

Cardiovascular

Cardiac output: remains elevated for 48 hoursuntil diuresis reduces blood volume; this is

riskiest time if woman has cardiac disease Hgb & Hct: depends on prenatal values,

amount of blood loss during birth (300 - 400 ml normal)

WBCs (up to 25,000/mm3) normal Hypercoagulable state increases thrombus risk Temp 100.4º F (38 º C) normal in first 24 hrs Varicosities regress after birth

4th Stage Labor AssessmentFrequency: Q 15 min x 4, Q 30 min x 2, Q 1 h x 1• BP, pulse, resp rate, (temperature x 1)• Fundus: palpate for height, position & firmness• Bladder: assess for distension• Lochia: amount, color & odor. Note number and

size of any clots. Weigh pads if > 1 pad/h• Perineum: assess for edema, hemorrhoids &hematoma. If incision, for REEDA (redness,edema, ecchymosis, discharge & approximationof skin edges)

Promote Urination

• Should void within 6 to 8 hours of delivery• Fundus will usually be displaced to the

right ifbladder full• Encourage voiding– Running water in sink– Hand in warm water– Low, open vocalizations• Straight catheterize as ordered if bladderfilling and unable to void

Promote Bowel Elimination

• Post op: auscultate BS, assess for flatus &

distension (avoid ice, sodas or apple juice)

• Promote bowel elimination:– Hot tea & frequent ambulation– Fluids and fibers– Stool softeners/suppositories– Teach to obey urge to defecate &

pushnormally but avoid straining

Promote Comfort

Perineum:• Ice pack x 6 hrs (or as ordered)• Sits bath x 20 min tid (need MD order)• Perineal care after each elimination: squirtwarm water over perineum, blot dry & apply

peripad front to back• Apply topical anesthetics or TucksAfterpains:• Warm blanket to abdomen• Relaxation breathing• Administer analgesics as ordered

Bonding/Attachment

• Process when parents form emotional relationship with their infant over time

• Mother explores first with fingertips, then palms, then with hands and arms

• Holds infant in face position about 20 cm apart and on same plane

• Uses soft, high pitched tone of voice• Engrossment: father’s absorption &

interest in infant; can be stimulated by witnessing birth

Promote Adaptation to Parenthood

• Rooming in• Pain relief for mother• Baby with parents/family after birth• Father sleep in room with mom• Teach parents infant comforting

techniques– Swaddling– Rhythmic motion (rocking or chicken walk)– Holding with pressure on tummy• Observe, listen and support

Promote Maternal Safety

• RhoGAM if needed– If Rh- mom with Rh+ father– 300 mcg IM by 72 hrs

Postpartum Discharge Teaching

General Instructions for Comfort and Activity

Rest for about half waking hours, alternating brief periods of activity with rest for a week.

Nap when the baby naps. After the first week, take an afternoon rest

of 1-2 hours each day. Shower or bathe freely. Eat three balanced meals a day.

General Instructions for Comfort and Activity

For painful stitches, soak in the tub (sitz bath) for 15 minutes, three times a day. Apply anesthetic spray or ointment as needed.

For hemorrhoids, use 15 minute sitz baths several times a day. Keep stool soft by drinking plenty of fluids and eating fruits and vegetables. You may use stool softeners, mineral oil, Tucks or suppositories as prescribed by your doctor.

For constipation, increase fluid intake, use mineral oil

General Instructions for Comfort and Activity

Do not douche, use tampons or vaginal suppositories for 6 weeks.

Do not engage in sexual intercourse for 6 weeks.

Climb whatever stairs are necessary. Avoid strenuous physical activity,

including exercise workouts, for 6 weeks following the delivery

Diet

Eat a well balanced diet including lean meats, fish, fresh fruit or juice, fresh vegetables, and dairy products.

Breast feeding burns about 300 calories per day. This will help you return to prepregnancy weight faster.

Drink eight to ten (8-10) glasses of fluid each day. Have a glass of water, juice, or low-fat milk each time you feed your baby.

Medications

Continue a daily multivitamin for as long as breastfeed.

If needed, doctor will order additional iron pills

You may safely use acetaminaphen, ibuprofen , or any other medication

Bleeding

May experience blood tinged or brownish discharge for 3 to 6 weeks.

The first menstrual period may occur from four to eight weeks after delivery, longer if breastfeeding.

The first period may be heavier than usual.

Breast Care

Call at the first sign of a breast infection (pain, redness or fever).

If not breastfeeding, use a tight, supportive bra for five days after discharge, avoid breast stimulation, and use ice packs to help with engorgement.

If breastfeeding, keep the breasts clean with frequent warm water rinses to clear dried milk from the nipples. It is generally better to avoid the use of soap on the breasts.

Danger Signs

Continuous abdominal pain Bad smelling vaginal discharge Heavy bleeding (a full sanitary

napkin in an hour) Pain or redness in the leg Difficulty urinating Temperature greater than 38 degrees Tenderness or localized redness of

the breasts